Health workforce capacity of intensive care units in the Eastern Mediterranean Region

Objective The onset of COVID-19 pandemic increased the need for functioning and equipped intensive care units (ICUs) with staff trained in operating them. In the Eastern Mediterranean Region, this also triggered the need for assessing the available capacities of ICUs and health workforce so that appropriate strategies can be developed to address emerging challenges of staff shortages in the wake of COVID-19. To address this need, a scoping review on the health workforce capacity of intensive care units in the Eastern Mediterranean Region was conducted. Methods A scoping review methodology as outlined by Cochrane was followed. Available literature and different data sources were reviewed. Database includes Pubmed (medline,Plos included), IMEMR, Google Scholar for peer-reviewed literature, and Google for grey literature such as relevant website of ministries, national and international organization. The search was performed for publications on intensive care unit health workers for each of the EMR countries in the past 10 years (2011–2021). Data from included studies was charted, analysed and reported in a narrative format. A brief country survey was also conducted to supplement the findings of the review. It included quantitative and qualitative questions about number of ICU beds, physicians and nurses, training programs as well as challenges faced by ICU health workforce. Results Despite limited data availability, this scoping review was able to capture information important for the Eastern Mediterranean Region. Following major themes appeared in findings and results were synthesized for each category: facility and staffing, training and qualification, working conditions/environment and performance appraisal. Shortage of intensive care specialist physicians and nurses were in majority of countries. Some countries offer training programmes, mostly for physicians, at post-graduate level and through short courses. High level of workload, emotional and physical burnout and stress were a consistent finding across all countries. Gaps in knowledge were found regarding procedures common for managing critically ill patients as well as lack of compliance with guidelines and recommendations. Conclusion The literature on ICU capacities in EMR is limited, however, our study identified valuable information on health workforce capacity of ICUs in the region. While well-structured, up-to-date, comprehensive and national representative data is still lacking in literature and in countries, there is a clearly emerging need for scaling up the health workforce capacities of ICUs in EMR. Further research is necessary to understand the situation of ICU capacity in EMR. Plans and efforts should be made to build current and future health workforce.


Introduction
Many developing countries had been facing a continued shortage of health workers and intensive care unit (ICU) facilities when the onset of COVID-19 pandemic significantly impacted delivery of health services across the world and increased the need for functioning and equipped ICUs with staff trained in operating them. This also triggered the need for assessing the available capacities of ICUs and health workforce so that appropriate strategies can be developed to address emerging challenges of facility and staff shortages in the wake of COVID-19 [1].
ICU provide patient care and treatment needed for critically ill patients. A consolidated, universal agreement however, of what constitutes an ICU is not available. Fundamentally, an ICU needs to be a well-organized combination of a well-equipped facility, infrastructure, equipment and a competent multidisciplinary team working within a structure based on technical standards and best practices [1]. The definition of an ICU and therefore their beds and capacities vary from country to country. This is a significant challenge when assessing resources and capacities in a country as well as comparing them with others [1].
The Eastern Mediterranean Region (EMR) has 22 member states, majority of which are low-and middle-income countries, and there is a very steep difference between the intensive care capacity of resource rich and resource poor countries within the region. The challenge is sparsity of national level data on ICU beds and qualified specialist physicians and nurses in acquiring a comprehensive and accurate assessment of local capacities. Table 1 indicates to the ICU capacity of countries from different income levels in comparison to some EMR countries where such information is available [2,3].
Similarly, the optimal model for staffing ICUs is still unclear and any recommendations available varies for different ICUs models such as high and low intensity ICUs. Depending on the ICU capacity, the optimum physician-to-patient ratio may vary but the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) recommends that a ratio of at least 1:8 specialist physician or intensivist is preferable and should not be lower that 1:15, findings consistent with other literature [4,5]. There is also an ongoing debate about whether or not round the clock presence of specialist physicians is necessary in these units, and while there is a considerable staffing cost and physician shortages to consider, the benefits do seems to outweigh the costs in high-volume, high-acuity ICUs [6].
Equally critical is the presence of specially trained nurses in the ICU. National recommendations for developed countries such UK and Australia require a minimum nurse to patient ratio of 1:1 for ventilated and other critically ill patients and 1:2 nursing staff for patients determine to be less critical [5,7]. As the ideal is often not possible in low resource settings, nurses are frequently left in charge of the patients in ICUs with nurse-to-patient ratio of 1:4 or even lower [8]. In any case, the number of staff required should be calculated according to the number of ICU beds, number of shifts per day, occupancy rate and overall level of ICU such as level 1 where patients do not require organ support or level 3 where patients require mechanical ventilation [9].
In the current context of the pandemic, the importance of timely access to emergency, critical and intensive care is being emphasized by countries and regions and the need for providing these services through integrated approaches. It is of interest to note that the World Health Organization (WHO) is responding to these calls by planning to support countries in strengthening their health service delivery through ECO-systems (emergency, operative and critical care services). It is a mechanism that ensures these services are accessible to people who need them through integrated planning that places longitudinal primary care at the centre of this system [10]. Research about intensive care is also low in the Eastern Mediterranean Region as in many developing countries [11,12]. A systematic review on intensive care unit capacity in 36 low-income countries found 50% of them did not have any published data on ICU capacity [13]. Therefore, in order to improve knowledge about the health workforce capacity of intensive care units in EMR, a scoping review of available literature and different data sources in the region was conducted. A brief country survey was also conducted to supplement the findings of the review. The survey aimed to capture the current capacities of ICU beds and health workforce involved in dealing with COVID-19 patients.
While the terms ICU and critical care may be used interchangeably in literature, critical care can often extend beyond intensive care units. This paper focuses on health workforce capacity of intensive care units and the term ICU will be used for consistency.

Objectives
• Provide an up-to-date and comprehensive overview of the current capacity of ICU workforce in the EMR member states.
• Reviewing the impact of COVID-19 on ICU capacity and the workforce in EMR.

Identifying relevant studies
A scoping review methodology as outlined by Cochrane and Joanna Briggs Institute manual was followed [14,15]. Two individuals independently searched four databases. Searches for peer reviewed literature included Pubmed (medline,Plos included) IMEMR Google Scholar and Google search engine). Grey literature was sought from Google as well as relevant website of ministries, national and international organization. The search was performed for publications on intensive care unit health workers for each of the EMR countries in the past 10 years, by combining search terms as well as free text depending on the database used, with no language restriction. Search terms used included "intensive care unit" "critical care" "intensive care" "icu" "workforce" "health workforce" "health care workers" "staff" "healthcare professionals" "physicians" "nurses" "developing countries" "Eastern Mediterranean". A 10-year search timeline between 2011 and 2021 was employed to include the most recent information and evidence in the region. Eligible articles were those that included critical care or ICU setting, bed numbers, staffing capacity, ICU training and qualification and performance appraisal. Articles that did not include health workers working in critical or intensive care unit settings were excluded, as well as those not published within the selected time period and those for which full text was not available. Additionally, reference lists of included articles were also reviewed to identify relevant literature. Mendeley was used to facilitate the screening process. Initial search yielded 599 titles, after removing duplicates and screening titles, 73 articles were screened for full text after which 63 were available for inclusion based on the inclusion criteria (Fig 1). In addition to that, after the data extraction from selected articles was completed using the data extraction chart, another screening was performed of all entries to exclude any studies not fitting the inclusion criteria.
Limitations included consulting limited number of databases and reviewing a limited number of journals. Certain articles may not have been retrieved if the name of the country was not mentioned in the title or abstract. This could have resulted in an underestimation of the number of publications on ICU health workforce in the Eastern Mediterranean Region.

Charting data
An excel spreadsheet was used to extract the data from 63 articles. The data extraction chart was developed with the consideration of the type of information to be extracted from the included literature to answer the research questions. It included title of the article, name of authors, journal and publishing date, type, aims and objectives of the study, countries the study is based in, design/methodology, findings, aspects of HWF related to ICU capacity and limitations of the study if reported.

Collating, summarising and reporting results
Data such as date of publication, authors, country of the study etc are straightforward to extract and allow for a description of papers included in the scoping review. Data from the included literature was reviewed and information most relevant to answer the review questions was extracted and charted it in the excel sheet. Scoping review guidelines do not call for analysis beyond basic descriptive analysis of content such as frequency counts of concepts, populations etc. [16,17] Information is synthesized descriptively and can be presented in categories or themes. A formal thematic analysis is beyond the scope of scoping reviews [18]. Upon review of the included articles, the extracted information was grouped under major themes, which were facility and staffing, training and qualification, working conditions/environment and performance appraisal. The results were grouped under these themes and re-analysed within each theme and if required content was moved within themes for a bitter fit. As the number of studies was limited, we included all the studies which were then carefully interpreted and reported. Quality assessment was not performed due to limited number of studies; therefore, all studies were included, and all data is reported in a narrative format.

Country survey
The questionnaire included quantitative and qualitative questions about number of ICU beds, ICU physicians and nurses, national training programs as well as challenges faced for ICU health workforce. Responses were received from six countries with national level reporting from Jordan, Afghanistan, and Pakistan. Palestine reported data for West Bank only and facility level data representative of ICUs across the country was provided by Djibouti and Oman and will be considered as representative at national level in this analysis.
An ethics statement is not applicable as this study is based on published literature and data which is publicly available within countries and/or government agencies.  Table 2 contains the number and type of publications included from each country. Majority of the articles were from Egypt, Iran, Jordan, and Saudi Arabia and focused on appraisal of certain practices and knowledge. Most publications (60% were cross-sectional surveys, only 4.7% were a qualitative examination of the subject and 20% were reviews or reports. Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Kuwait, Lebanon, Sudan (40%) had facility level studies. Djibouti, Libya, and Morocco (13%) were also part of regional level studies while Jordan, Somalia as well as Libya (13%) had both national and facility level studies. National level studies were retrieved for Saudi Arabia, Pakistan, Oman, Syria, Tunisia, and Yemen (27%). No publications were found for UAE.

Facility and staffing
Comprehensive and accurate data on facility and staffing can be vital for planning and providing quality healthcare. In this scoping review, very few studies had estimates of ICU beds in a country. However, with the onset of the pandemic, increase in ICU beds across countries was reported to cope with the overwhelming number of cases requiring intensive care due to COVID-19 infections. Survey findings also demonstrated the difference in actual and surge capacity as hospitals beds and other resources in hospitals were converted into flexible ICU beds for treatment of COVID-19 patients. Some countries responding to the survey reported nearly doubling their ICU capacity (Fig 2): Percentage of permanent ICU beds out of total hospital beds in Jordan was 6.1 which increased to 17 percent when accounting for the additional ICU beds converted for COVID-19 response [19] Similarly in Oman, permanent ICU beds made up 4 percent of total hospital beds while additional ICU beds raised the proportion to 7.8 percent. Afghanistan reported an increase in its ICU beds from 3.9 percent to 6.4 percent. In other countries, the increase with additional ICU beds was a little lower. Example of Pakistan, reporting an increase from ICU beds comprising 1.3 percent of total beds to 2 percent. West Bank increased its ICU beds from 4.2 to 5.8 percent.
Health worker shortages were referred to in literature but exact numbers of ICU health workforce at the national level were not available for many EMR countries and physician and nurse to patient ratio were mostly reported for facility level [20] Most of the data found in literature was related to anaesthesia physicians as it is common in many countries for anaesthesiologist/anaesthesia physicians to run intensive care units or serve as consultant physicians.
In the Tunisian health system, public sector medical ICUs were generally managed by medical intensivists and surgical field managed by anaesthesiologists. Private sector ICUs usually managed by anaesthesiologists recruited on a full-time basis [21] One of the studies on Africa's critical care capacity before the COVID-19 pandemic, published in 2020, reported density of anaesthesia physicians in Djibouti and Egypt to be 1.01 per 100,000 population and 6.01 per 100,000 population respectively [22] A survey performed in 2020, of 16 hospitals in Libya, found that intensive care specialists were available 24 hours a day in nine (56.3%) hospitals, four hospitals had them on call for 24 hours a day and three hospitals didn't have the 24 hours presence of such specialists. Nurse-topatient ratio ranged from 1:1 in some ICUs to 1:4 in other [23] The Lebanese Critical Care Society approved by the Lebanese Order of Physicians has over 100 critical care physicians in its membership from different specialties such as pulmonary, anaesthesiology, internal medicine-which may be taken as in indication to their number [24].
The country survey also showed that majority of intensive care related specialists were qualified as anaesthesiologists followed by internal medicine. In all six responding countries qualified intensivists comprised of very low numbers ranging from none in Afghanistan to 1 in West Bank, 2 in Jordan, 8 in Pakistan, and 49 in Oman (data from 2020-2021). Afghanistan also had one of the lowest availabilities of ICU staff reported by the countries with only one physician per 5-10 beds and one nurse per 3-5 beds. Djibouti reported 1 physician for 6 beds and one nurse for 3 beds, Jordan reported nurse to bed ration ranging from 1 per 4 beds to 1 per 5-8 beds while West Bank and Pakistan reported non-availability of such numbers.
Nurse-to-patient ratio in a Moroccan tertiary care ICU was found to be 1:2 during the day and night shifts [25]. A national level study conducted in 151 hospital ICUs in Pakistan found 1:1 nurse to bed ratio during the day was only available in 53.5 percent of units, dropping to 47.8 percent during the night shift. A senior clinician trained in intensive care was available in only 12.1 percent of ICUs. For Jordan nurse-to-patient ratio reported in the country survey ranged from 1:4 in JUH, 1:5 in RMS and KAUH to 1:8 in MoH. Overall, severe staff shortages were reported in the survey, especially of physicians and nurses trained in intensive care.

Training and qualification
Training of health workforce for intensive care differs across countries and is done through a variety of programmes including master's degree, post-graduate training, diplomas, and short courses. Literature on training of doctors, nurses and physiotherapists were found in Bahrain, Egypt Iran, Iraq, Jordan, Libya, Morocco, KSA, Pakistan, Syria, and Tunisia. Further information of available training programs in Afghanistan, Pakistan, Oman, Jordan, and Palestine was also obtained through the country survey.
Several countries have post-graduate clinical training programmes which are generally 4 to 5 years in length as shown by the findings from the scoping review and country survey. These include a 5 year-critical care residency programme for physicians offered by The Saudi Board of Critical Medicine and a 4-year critical care medicine fellowship for physicians in Pakistan under College of Physicians and Surgeons (CPSP) [26,27]. Graduates in Tunisia have two pathways for specialization in critical care: a 5-year curriculum of anaesthesiology and surgical intensive care medicine or 4 years in medical intensive care medicine [21]. Graduates in Libya can specialize in anaesthesia and intensive care under the Libyan Medical Specialties Board as well as from Arab Board of Health Specializations in Anaesthesia and Intensive care [28]. The Arab Board of Medical Specialization was founded by the Council of Arab Health Minister of the Arab League and is responsible for establishing certification procedures for a wide range of medical specialties in coordination with teaching institutions in its member countries [29].
Jordan not only has a residency program by the Department of Anaesthesia and Intensive Care at Jordan University Hospital (JUH) but the Ministry of Health also sends it ICU, Respiratory and Pulmonary physicians to JUH for a 2-3 year specialization as part of its CPD program [19,30].
Specialization through master's degree is also an option in some countries though few appeared in the review search such as master's degrees in intensive or critical care available for nurses in Bahrain, Iran, and Jordan [31,32]. Literature for Jordan also indicated presence of MSc and doctorate for ICU physical therapists [33]. Several short courses are also offered for physicians and nurses in the region such as a 9-month diploma in critical care for bachelor's degree holder in Jordan and a Post-RN diploma in emergency and critical nurses in Pakistan. Oman also offers critical care diplomas for nurses in adult critical care and fundamental critical care support [19]. In Libya, the Centre of Development of Medical Manpower plays a major role in continuing medical education and conducts 18-month training sessions for specialized qualification in intensive care [28].

Working conditions/environment
Working conditions and environment can have a notable impact on performance, motivation, turnover, and job satisfaction. 16 studies on related topics were found from Bahrain, Egypt, Iran, Jordan, and Libya. High level of workload and stress is a consistent finding across all countries often resulting from shortage of available staff. 57.1% of intensive care nurses working at a Bahraini hospital were uncertain if they wanted to continue working in ICU and only 21.4% were satisfied working there [34]. 68.2% of ICU health workers in an Egyptian study reported moderate burnout and over 50% of nurses had high level of emotional exhaustion compared to 38.8% of physicians [35]. Similarly, 96% of ICU nurses in a study from Iran had high risk level for secondary traumatic stress and 42% for burnout [36]. Jordanian ICU nurses were found dealing with higher job stressor compared to nurses in other wards and a cross-sectional study in two Somalian hospitals found work overload, role ambiguity and conflict were significant stressors for ICU staff [37,38]. Survey findings corroborated with these results with all countries reporting very high workload, high turnover, severe shortage of physicians and nurses specialized in intensive care, especially exacerbated due to COVID-19. Jordan's survey response highlighted that in the beginning on the pandemic some staff members had to stay in health facilities for over a month at a time in addition to the risk of getting infected. Several countries also mentioned the continuous rotation of limited number of specialists being rotated between ICU and other departments results in disruption of availability in some departments.

Performance appraisal
Performance appraisal is especially important in healthcare settings to identify learning and continuing development needs and demonstrate competency in practice among other benefits. A total of 17 studies evaluated competency and performance of ICU health workers and nearly all of them were focused on nurses. Gaps in knowledge were found regarding importance of reporting medication errors, management of critically ill patients, stroke and ventilator associated pneumonia in studies from Egypt, Iran, Jordan, and Kuwait. In an Iranian PICU, 74.8% of neonates experienced at least one medication error, 57% made by physicians and 43% by nurses [39]. 56.4% of critical care nurses in a Kuwaiti hospital passed the skills exam for CPR while only 15.7% passed the knowledge test. Jordanian studies indicated that failure to report medical errors was largely because nurses did not think the errors were serious enough [40]. Studies based in Egypt, Jordan, Saudi Arabia and Iran found ICU nurses to be not fully compliant to critical care guidelines and recommendation for procedures like endotracheal intubation and one of the main reasons were lack of time [41][42][43][44][45][46][47][48]. It was also demonstrated that performance of ICU nurses improved when exposed to focused training courses [49,50].

Discussion
While, in many countries, respective national societies of intensive care collect data to capture the ICU capacity in their countries which can be publicly accessible, this was not the case in EMR [51]. Moreover, studies focusing on staffing were mostly limited to facility level which is not necessarily nationally representative especially in countries with a sharp rural-urban or geographical disparity in availability of resources. Difference between the availability of the ICU resources between urban and rural areas, which is important in terms of equal access the ICU care, could not be captured in this review. Regarding to the nurse-to-patient ratio at ICU in EMR (1:1 to 1:8), it has less capacity compare to Asian countries (1:1 to 1:3) [52] Scaling up of resources in response to the COVID-19 pandemic was observed however, it raised an important point of concern about how countries managed to increase workforce capacity in intensive care for treating COVID-19 patients in a short period of time and how that may impact quality of care. At global level, it has findings that anaesthesiologists play a central role in ICU in providing patient safety and performance improvement due to their strength in sedation procedure, mechanical usage, and rapid response, and this practice is commonly seen in EMR as well [53]. Similar management of ICUs was found in African regions, such as South Africa [54]. Increase in ICU beds and admissions also meant severe shortage of physicians and nurses, especially ICU specialists, continuous rotation of limited number of specialists in ICU departments and significant increase in workload. Relying on fragmented data for planning to overcome health workforce shortages and other needs of health systems can result in weak policies and delay progress. Obtaining accurate and comprehensive baseline data and establishing up-to-date data bases of critical care workforce is therefor, essential for evidence-based policy decisions.
None of the included studies explored the presence of intensive care training programmes but rather other aspects and impact of training programmes. Ideally, the healthcare workers would be qualified and certified in the field of intensive care. However, a limited number of countries (Bahrain, Egypt, Iran, Jordan, Pakistan, Syria, Tunisia, Saudi Arabia) have established a training program at the post-graduate level to train ICU physicians, nurses, and other health workers. Previous research has suggested that having a certified nurse specialist in intensive care with advanced skills as a head nurse in the ICU may help to improve patient outcomes by leading the team to optimal solutions [55]. There are several established training programs such as a five-year residency program for physicians in Saudi Arabia and a four-year fellowship in Pakistan in the literature, a master's degree in intensive care for nurses in Jordan and the critical care diploma for nursing in Oman in the survey. In contrast, survey, and literature findings both found accounts of lack or absence of training programmes, curriculum's insufficiency and ineffectiveness, inefficient planning, ineffective implementation, and lack of correlation between job description and curriculum. Such shortcomings in education and training programmes are a challenge in producing a well-trained and high-quality workforce. This in-turn has implications on the delivery of required health services, quality of care and overall performance of health system. Countries in the region must invest in establishing and scaling up relevant post-graduate and specialty programmes with uniform curricula and ensure their implementation. Equally necessary is access and availability of continuous professional development opportunities for ICU workforce.
Majority of studies grouped under the theme of working conditions and environment have looked into mental health issues and job satisfaction among personnel working in ICUs. As mentioned earlier and consistent with findings from other studies, health workers stationed in ICUs work under significantly higher stress and trauma risk factors compared to those in other hospital wards or units. Nearly all the studies in the review focused on nurses working in ICUs and it is clear they work under not just physical burnout but also emotional exhaustion. The issue of burnout among the ICU staffs is widely observed in multiple countries outside of the EMR as well. For example, a systematic review of burnout in ICU professionals revealed the prevalence ranged from 6-7% in 25 countries [56]. Gaps in knowledge about many basic procedures performed in ICUs, lack of awareness about the importance of reporting medical errors and poor adherence to recommended guidelines reflects the need of continued medical education, increased active learning instead of lecture-based and better engagement with the health workers for an improved understanding of their needs and experiences. Studies also showed that active learning and continued education does improve the performance of ICU staff and adherence to guidelines which is an important insight for preparing a competent health workforce equipped to deal with ongoing and future public health emergencies. All the findings discussed above imply safety and quality concerns in health services. Increased workload as a result of staff shortages limit the ability of critical care nurses to deliver quality patient care and increases the risk of infections and decreases positive outcomes for critically ill patients [57,58] Working under physical and emotional burnout, and inadequate knowledge of basic critical care procedures increases risk of medical errors, poor adherence to recommended guidelines, puts the safety of patients and health workers at risk and has negatively affects the quality of care [59].

Conclusion
Although the literature on ICU and ICU capacities in the Eastern Mediterranean Region was found to be limited, it did provide valuable information on certain aspects of ICU health workforce capacity. Despite the absence of baseline data on ICU capacities before the COVID-19 pandemic, it is clear that many countries in the region struggle with challenges of increased workload, mental health stressors, training, and competency of their health workers in ICUs, exacerbated further with the onset of COVID-19 pandemic. Well-structured, up-to-date, comprehensive and national representative data is still lacking in literature and in countries. This is particularly relevant to ICU bed capacity, number of qualified and trained staff available and ratio of physicians and nurses to ICU beds. It is apparent from the fragmented information in literature that there must be a functioning health workforce information system with adequate disaggregation in all countries which will provide crucial information for capacity planning and resource allocation.
The need for scaling up health workforce capacities of ICUs is a clearly emerging need in EMR. The plans and efforts should be made to build current and future health workforce. In the short-term, countries may repurpose some of the existing health workforce with shorter training programmes while establishing and scaling up relevant post-graduate and specialty programmes for health professionals, especially for physicians and nurses. Simultaneously, continuous professional development opportunities should be made available to current and future ICU workforce.
With the challenges mentioned it is also equally important that interventions to increase the resilience of health workers to phycological burden and workload stresses are in place as well as reducing the workload with appropriate health workforce planning. As countries in the Eastern Mediterranean region continue to battle COVID-19 while many face existing challenges with limited resources, complex emergencies and protracted crisis, initiating a systematic and sustainable health system strengthening in critical care and ICU is urgently needed with full engagement from the regional and global community.